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Aviation Human Factors Industry News

May 04, 2006

Vol. II, Issue 17.


NTSB Says Poor Maintenance, Weight Issues Caused 2004 Convair 340 Accident

Cargo Plane Crew Ditched In Lake After Engine Failure The National Transportation Safety Board has determined that improper maintenance procedures and weight issues were behind the December 4, 2004 downing of a vintage twin-engine Convair 340. The plane went down in a Florida lake after the aircraft's left engine failed.

As Aero-News reported at the time, the two pilots onboard the plane -- who survived the accident, and were later hailed as heroes -- turned the plane back towards Opa-locka Airport after the engine failed. They almost made it... but were forced to ditch just short of the airport, near Aventura, FL.

In its Probable Cause report, the NTSB states improper maintenance of the left engine by company maintenance personnel, including the failure to flush metal from the oil system and failure to properly preserve the engine for storage, resulted in a total failure of the master rod bearing and contamination of the engine oil system with metal.

Not only did that choke the engine... it also prevented the pilots' ability to feather the left propeller, which created additional drag as the pilots attempted to steer the bird back to Opa-locka.

Even if the propeller had functioned normally, however, the plane may still not have made it back to the airport ... as the NTSB also determined the aircraft was overloaded.

An FAA review of the cargo manifest discovered two different manifest weights -- a manifest obtained at the accident scene that showed a total of 267 pieces of cargo annotated at a total weight of 10,837 lbs., and also a sealed cargo manifest package showed a total of 267 pieces of cargo annotated at a total weight of 14,182 lbs -- which exceeds the maximum payload weight for the Convair 340 by just under 600 pounds.

The plane had been heading to Nassau, FL when the accident occurred.

A Cloud Hangs Over Airbus

RUSSIAN officials have identified severe weather as the likely cause of the crash off Sochi, and an air traffic controller is under investigation. But the accident may revive questions about the high-tech design of the Airbus A320 and the crew’s ability to handle it.

The short-to-medium haul A320 was the first all-electronic "fly-by-wire" airliner. More than 2,700 have been produced since 1988, and it has proved one of the world’s safest airliners. Before now, 11 fatal A320 accidents had killed 327. But four fatal crashes in the first five years of the A320 prompted concern that its flight management system (FMS) was too sophisticated.

On Tuesday a court in France began hearing criminal charges against Airbus and transport officials over the crash of an Air Inter (now Air France) A320 on the approach to Strasbourg in 1992, killing 87. The crew was officially blamed for entering data into the FMS incorrectly but relatives of victims are partly blaming its crew interface, which was later modified by Airbus. In 1993 the A320 design was blamed for the late deployment of the brakes on a Lufthansa A320 when it ran off the runway in Warsaw, killing two.

Since the early 1990s, there has been no common thread to incidents with A320s or the larger Airbus family.

In 2000 pilot error was blamed for a disaster involving a Gulf Air A320 that killed 143 off Bahrain. That crash was in good night-time visibility, but it otherwise resembled yesterday’s accident because the crew were turning back over water after a missed approach. The relatively inexperienced crew lost their bearings and flew into the sea. Some aviation experts at the time questioned the role of the automated system.

NTSB Rules Poor Planning Led To 2004 Cargo Plane Accident

Pilot Initiated Fuel Transfer, But Failed To Notice As Tank Ran Dry What happens when you don't properly plan for a flight? Sometimes, the very worst... and the NTSB says that's what happened in the case of an Air Tahoma Convair 580 that went down near Cincinnati in August, 2004.

Investigators found the plane's pilot, Bruno Pichelli of Welland, Ontario, spent most of the flight doing fuel-weight calculations that should have been completed before takeoff. The investigation also found Pichelli initiated a crossfeed fuel transfer about 50-minutes into the flight -- then let it continue unmonitored, while he attended to his calculations.

The fuel shut-off valve was left open during the transfer. As a result, investigators say, the left tank ended up dry. The engines quit, because they were both feeding off the left tank.

As Aero-News reported, the 1950s-era twin-turboprop which was carrying cargo for DHL -- went down on a golf course near Florence early in the morning August 13, 2004. Copilot Michael Gelwicks of Southaven, MS was killed in the crash.

"Here again we see the tragedy that can result when time-tested procedures are not respected," said NTSB Acting Chairman Mark V. Rosenker. "The accident also points up the severe consequences that can follow when the operator of an aircraft, or any other vehicle, becomes distracted."

The NTSB's finding of probable cause lists as factors the captain's inadequate preflight planning, his subsequent distraction during the flight, and his late initiation of the in-range checklist." In addition, "the flight crew's failure to monitor the fuel gauges and to recognize that the airplane's changing handling characteristics were caused by fuel imbalance."

The Board also recommended that the FAA issue a flight standards information bulletin to familiarize Convair 580 operators with the circumstances of the Air Tahoma accident, including the importance of closing the fuel tank shutoff valve for the tank not being used during crossfeed operations.

Noting that additional details about the flight crew's actions after the loss of engine power would have aided the investigation, the Board also reiterated a previous recommendation to the FAA (A-99-16), which called for retrofitting airplanes with independently powered cockpit voice recorders.

Air Crash Probe Disappoints Ebersol

No investigation or air safety reforms will numb the pain of losing his 14-year-old son, Edward "Teddy" Ebersol, in a horrific plane crash, Dick Ebersol acknowledged Tuesday. But the NBC executive and Litchfield resident said he was disappointed a federal probe into the snowy November 2004 accident in Colorado failed to scrutinize a company that farmed out the doomed flight and another that hired pilots deemed inexperienced in winter weather.

"I didn't come down here expecting that the miracle of seeing Teddy again would happen today, but I thought they'd be a little more pointed in asking questions about who put these pilots in the cockpit of that plane that Sunday morning," Ebersol said in a phone interview from Washington after attending a National Transportation Safety Board hearing into the Nov. 28, 2004, crash.

The panel concluded Tuesday that the pilots' failure to touch the wings when checking for ice - they only checked visually - caused the plane to bounce on its wings and skid down the runway at the Montrose, Colo., airport. The jet caught fire and exploded.

Teddy Ebersol, pilot Luis A. Polanco-Espiallat and flight attendant Warren Richardson III were killed. Dick Ebersol, his older son, Charlie, and co-pilot Eric Wicksell were injured but survived.

Dick and Charlie Ebersol told investigators the runway was covered with an inch of slush before takeoff. "Neither the captain nor the first officer had any winter weather flying experience," the report stated in citing the pilots' lack of experience in snowy conditions.

Even more egregious, says Ebersol, who broke several bones in the crash, was that Key Air Inc., the Oxford-based company he says he used for personal air travel for a decade, failed to let him know it would not charter the flight.

Instead it secured Air Castle Corp., a New Jersey-based outfit, to charter the several-stop, cross-country flight his family needed to get from California back to the East Coast. The plane stopped in Colorado to drop off Ebersol's wife, actress Susan St. James, and was scheduled to stop next in South Bend, Ind., to drop Charlie Ebersol at college when it crashed.

Key Air, implicated in the bid-rigging scandal that put former Gov. John Rowland in jail, normally cleared all the pilot's safety credentials with his office, which also used the carrier, before flying, and informed if there would be a change in carrier, Ebersol said. "Having cleared all my private travel flight on private carriers it's pretty stunning to find out you've been put on some other plane," he said.

"Them not having their eye on the ball - we don't have our little boy anymore," he added.

But, Key Air chief operating officer Brad Kost wholly disputed Ebersol's claims. "Our deepest sympathy to his family," Kost said Tuesday. "But the facts show that his office did know the aircraft was not one of our aircraft."

Kost said that Ebersol's office requested that Key Air find another carrier for the charter flight because the company's fare was too high. It is rare for his firm to contract with other firms to charter flights, Kost said, but it chose Air Castle because it had among the highest ratings in the industry and boasted a "zero accident, zero incident safety record" that was confirmed by the FAA.

Reached for comment about Kost's claims, Ebersol's Chicago-based attorney Robert Clifford said that Ebersol's office had nothing to do with arranging his personal travel and called Kost's account a "reconstruction of history."

For its part, Air Castle Corp., through spokesman Chuck Wyble, said Polanco-Espiallat, 50, had 12,000 hours flight experience and dealt with icy and snowy conditions while being based for four years at the Teterboro, N.J., airport. Wyble acknowledged co-pilot Wicksell had "limited experience" relative to the captain.

In an attempt to clear his name, Polanco-Espiallat's family has also pointed out that the plane manufacturer revised its flight manuals after the Colorado crash and the NTSB issued an advisory about ice accumulation on wings in the same month. "The bigger issue here is that the FAA and the NTSB damn well knew this was starting to become an issue in this type of airplane but they didn't do anything about it," Brian Alexander, the family's attorney, said.

Polanco-Espiallat's flying credentials came under scrutiny in February when a letter was released in an initial NTSB report that stated he had not flown enough in the previous 14 months prior to the flight to meet the qualifications of Wyvern Standard LTD, a global aviation safety consultant.


Board members on Tuesday appealed to the FAA to develop training aids for all commercial pilots on how to feel their aircraft's wings for ice and better prepare to fly in wintry weather, and recommended that the Department of Transportation require charter airlines to inform passengers of the name of the company operating the flight.

Business relationships among charter airlines "appear to be a shell game, which is at worst dangerous and at best confusing," board member Debbie Hersman said.

Ebersol said he hopes that such practices will become more transparent as a result of the lens that has been held up to the crash that caused his son's death. "I just want no other family to go through what we've been through,"

he said. "Because your children are meant to outlive you."

JAL opens Safety Promotion Center

The JAL Group has established a Safety Promotion Center featuring exhibits from incidents and accidents primarily as an aid to encourage flight safety awareness among employees.

Located in the maintenance district of Tokyo’s Haneda Airport, the Japan Airlines Safety Promotion Center will open on April 24, 2006. It has been created in response to recommendations from a five man external panel of safety experts established by JAL in 2005 and chaired by Kunio Yanagida, a well-known writer specializing in scientific, aviation, and crisis management topics.

JAL has spent 180 million yen (US$1,525,400) in creating the facility, which has a staff of three.

Exhibits in the 622 square meter display space include photographs, charts and other items from a JAL 747-accident in August 1985. These items include the flight data recorder, cockpit voice recorder and seats from the aircraft, which was flying from Tokyo to Osaka when the accident happened.

A major exhibit is the rear pressure bulkhead from the aircraft (registration JA8119). This fractured in flight, severing hydraulic lines and blowing off most of the aircraft’s tailfin, thus rendering the aircraft uncontrollable.

Documentation and information providing case histories of accidents and incidents for reference and study are compiled at the center in an archive, available for reference at anytime. The center’s displays and documents will be used for employee education and training and will also be available to serious researchers outside the company.

The center displays information on all accidents JAL has been involved in since its founding and also includes materials showing what other airlines in Japan and throughout the world have learned from accidents, and how they have applied their learning to improving safety.

Continental Express jet lands safely with blown tires                      Low tire pressure or tire/s out of serviceable wear limits or just FOD?

HOUSTON (AP) --- A Continental Express plane made an uneventful emergency landing Tuesday after blowing a tire upon takeoff at Houston's Bush Intercontinental Airport.

The twin-engine plane, bound for Minneapolis, reported the problem at 4:25 p.m. CDT, circled the airport to burn fuel and landed safely at 6:22 CDT.

Emergency crews rushed to the plane, which landed with no visible sparks.

Aerial video of the Embraer 145 plane showed the left tires on the landing gear nearly stripped of rubber.

The plane, which was en route to Minneapolis, tried to land once, but was waved off. It was ordered to do a second flyby of the airport so officials could assess the damage and allow the plane to burn fuel before it could land, said Continental Express spokeswoman Kristy Nicholas.

Older pilots crash in disproportionate numbers

LOS ANGELES - At 50, Philip Semisch learned to fly. He took aerobatic lessons on his 60th birthday. When he turned 70, he flew gliders.

Another aviation milestone followed just a few years later: He crashed.

The retired Army officer and manufacturing executive from Skippack, Pa., was alone, piloting a small Decathlon plane in September 2002. It bounced as he tried to land, twice. As he took the plane back up for another landing attempt, he failed to clear a wall of trees and crashed.

Semisch walked away with bruises and a few stitches.

"I feel very comfortable flying, and did immediately after my accident," he said. "I take it very seriously. I don’t fly in bad weather. I’m careful."

Despite such confidence, Semisch’s Pennsylvania accident was one of hundreds in recent years that illustrate a trend within the general aviation industry: A disproportionate number of crashes among older private pilots.

Following a rash of plane crashes involving older pilots in Southern California, The Associated Press analyzed five years of federal pilot licensing documents and aviation crash data. The analysis showed that pilots in older age groups were in a significantly higher percentage of crashes than they represented among all pilots.

Fatal crashes also are proportionally higher for older pilots, according to AP’s examination of Federal Aviation Administration and National Transportation Safety Board data.


The findings come after an FAA rule change in September 2004 made it easier for graying pilots to obtain and keep licenses to fly certain smaller planes. Although they still must pass regular flight tests, the sport pilot rule eases medical restrictions.

It allows pilots to fly using only a driver’s license as proof of good health, a change that the FAA and pilots say would be of particular benefit to older pilots. Pilots whose licenses were revoked for health reasons — such as a history of heart problems — may be recertified after a medical exam and are not be required to undergo future checkups.

The general aviation industry is graying; the average age of private pilots rose from 43 in 1995 to 47 at the beginning of last year.

Experts widely acknowledge that about three-quarters of all aviation accidents are caused by some kind of pilot error, including slower reactions that can come with age.

"We don’t see too many aviation accidents that are related to a medical cause. The increase in accidents (with age) may be due really to cognitive factors," said Federal Air Surgeon Jon Jordan, the FAA’s top doctor.

Many pilots interviewed for this story defended aging aviators, saying wisdom and experience more than make up for any age-related forgetfulness or decline in motor skills.

"The statistics don’t support planes falling out of the sky," said Phil Boyer, president of the Aircraft Owners and Pilots Association, which claims more than 400,000 members.

There has been only one major jetliner accident in the U.S. in the last three years — at Chicago’s Midway Airport — but crashes of small airplanes have become nearly routine. On an average day in 2005, there were four general aviation accidents, with at least one accident-related death.

More than 500 people have died in general aviation crashes during each of the past three years. Historically, about 90 percent of all plane accidents involve general aviation. (By contrast, more than 30,000 people die each year in car and truck accidents.)


From the 1920s, every pilot, private and commercial, was required to pass a physical exam administered by an FAA-certified doctor — at least once every two years for those age 40 and older.

In 2004, the FAA, charged with both regulating and promoting aviation in the United States, rolled back its medical requirements for those flying certain small airplanes. Pilots of small "low and slow" aircraft now can use driver’s licenses as proof they are healthy enough to fly.

The Aircraft Owners and Pilots Association had pushed for the rule change, saying medical exams were unneeded. "There has been no history that having that medical exam creates a safer environment," said Boyer, the group’s president.


The rule change is "an extension of the philosophy that people have a responsibility for their own safety and health," said Jordan, the federal air surgeon.

Some pilots interviewed by AP said even under the old rule, it was common for older pilots to seek doctors who would administer only a rudimentary physical exam.

Fred Austin, a 60-year-old pilot from Sedona, Ariz., said his former medical examiner would have him hop on one foot for a few seconds: "Then he’d stand a few feet away and whisper, ‘Fred,’ to check your hearing. ... That’s all it took."

Many older pilots said they already monitor their health and don’t take unnecessary risks.

"Being prepared prevents accidents, and doing proper training prevents accidents," said Semisch, the pilot who learned to fly at 50 and survived a crash two decades later.

Lack of Sleep & Hypertension

In a study of more than 4,800 men and women, those who got five hours of sleep a night or less were about 60% more likely to develop hypertension than those who slept six to eight hours. The study consisted of people ages 32 to 59 and controlled for many variables, including depression, alcohol consumption, smoking, obesity. Long sleepers, 9 or more hours, were no less likely to have high blood pressure than those who slept six to eight hours. Lack of sleep may also increase the effect of other hypertension risk factors, such as obesity. (Nicholas Bakalar, "Research Ties Lack of Sleep to Risk for Hypertension" The New York Times, April 18, 2006)

The effects of shiftwork on sleep vary according to the shift worked. Not surprisingly night shift workers report the shortest and poorest quality sleep. Circadian data tells us that the percentage of workers getting six hours of sleep or less is almost double on the night shift compared to the morning or evening shift (41.5% versus 22%). As we all know, being sleep deprived doesn’t help anybody. Therefore it is important for shiftworkers, especially those who work nights, to be educated about ways to improve the quality and length of daytime sleep. As the hypertension study reports, even an extra hour of sleep can make a substantial difference for a person’s health.

END with thanks to jetBlue